Ablative therapies for colorectal liver metastases: a systematic review

AIM

The standard treatment for colorectal liver metastases (CRLM) is surgical resection. Only 20-30% of patients are deemed suitable for surgery. Recently, much attention has focused on ablative therapies either to treat unresectable CRLM or to extend the margins of resectability. This review aims to assess the long-term outcome and complication rates of various ablative therapies used in the management of CRLM.

METHOD

A literature search was performed of electronic databases including Medline, Cochrane Collaboration Library and the National Library of Medicine's ClinicalTrials.gov. Inclusion criteria were ablation for CRLM with minimum 1 year follow-up and >10 patients, published between January 1994 and January 2010.

RESULTS

In all, 226 potentially relevant studies were identified, of which 75 met the inclusion criteria. Cryotherapy (26 studies) had local recurrence rates of 12-39%, with mean 1-, 3- and 5-year survival rates of 84%, 37% and 17%. The major complication rate ranged from 7% to 66%. Microwave ablation (13 studies) had a local recurrence rate of 5-13%, with a mean 1-, 3- and 5-year survival of 73%, 30% and 16%, and a major complication rate ranging from 3% to 16%. Radiofrequency ablation (36 studies) had a local recurrence rate of 10-31%, with a mean 1-, 3- and 5-year survival of 85%, 36% and 24%, with major complication rate ranging from 0% to 33%.

CONCLUSION

Ablative therapies offer significantly improved survival compared with palliative chemotherapy alone with 5-year survival rates of 17-24%. Complication rates amongst commonly used techniques are low.

Do predictive scoring systems have any role in determining treatment strategy for colorectal liver metastases at the individual patient level?

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Background: the literature contains four prognostic scoring systems from large volume series predicting survival after resection for colorectal liver metastases. Our aim was to directly compare these systems in terms of accuracy in predicting survival, and evaluate the role of such systems in determining therapeutic strategies on intention to treat at the individual patient level. Methods: the original published data were reviewed and the median survivals plotted against each point in the scoring system. The best fit line was drawn and the resultant plots enabled calculation of slope of the linear regression line and the square of the Pearson product moment correlation coefficient through data points allowing all four prognostic scoring systems to be directly compared. Results: when the prognostic scores were compared on a common scale, the R-squared values of all the scoring systems were similar with R-squared values of greater than 0.94 in all cases. The Basingstoke Predictive Index however produced the steepest gradient suggesting it can better distribute patients along a wider range of survival. Conclusions: none of the four scoring systems was perfect in their predictive value. It is not surprising that the risk score from MSKCC and Leeds are not as good as the others since they are meant to be preoperative prognostic scores and postoperative scoring system by their nature of having more information should be better. Clearly, future developments in this field must incorporate advances in our understanding of tumor biology.

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Topical Biafine and Lipiderm for the prevention of radiation dermatitis: a randomized prospective trial

We evaluated the effects of Biafine and Lipiderm ointments in preventing radiation dermatitis. The study population included 74 patients after conservative surgery for early breast carcinoma who were referred for adjuvant external beam irradiation. Patients were randomized to receive Biafine or Lipiderm or no treatment. Both study preparations were applied twice daily, starting 10 days before onset of radiotherapy and continuing until 10 days after its completion. The skin treatment was upgraded, if clinically necessary, to steroids (grade 3), antibiotics (grade 4), or pause in therapy (grade 5). Success of treatment was evaluated according to the maximal level of skin treatment, the number of gaps in radiation therapy, the impression of the patients and the subjective skin reaction, and scores of the study nurse and radiotherapist. The three groups were comparable for all clinical features, except for a lower mean age of the Biafine group. Comparative analysis of the results showed no advantage for either preparation compared to the control arm other than maximal treatment level required for a skin reaction (mean 1.7 and 1.6 vs. 2.2), which did not reach statistical significance (p=0.145). Nevertheless, 86% of the patients in both the Biafine and Lipiderm arms expressed satisfaction with the respective ointments. In conclusion, neither Biafine nor Lipiderm seems to have a radioprotective effect.

RELATIVE CHANGES IN SALIVARY SODIUM AND POTASSIUM IN RELATION TO EXPOSURE TO HIGH G STRESS

Salivary Na+ and K+ was studied in 16 fighter pilots who were undergoing one week of intensive training for improving their tolerance to G stress. Their saliva was collected on first, third/fourth and sixth day of training. The subjects were also administered a stress coping strategy inventory to obtain scores on their pattern of stress coping. The results showed that K+ increased by 9.45 mEq/1 (p < 0.01) whereas Na+ decreased by 3.58 mEq/L (p > 0.05) under peak stress situation. Both K+ and Na+ showed a non significant decrease of 4.81 and 2.93 mEq/1 respectively in third sample (post stress) compared to second sample (peak stress). K+ concentration in saliva showed a transient phasic shift whereas Na+ concentration showed a more persistent tonic shift in relation to G stress. Regression analysis showed significant positive correlation of baseline Na+ with score on danger control strategy. A significant negative correlation was found between score on danger control strategy and baseline and poststress K/Na ratio.

Administration of half-dose theophylline together with ketotifen to asthmatic children--a double-blind, placebo-controlled study

Administration of theophylline to asthmatic children is frequently associated with an adverse influence on their behavior. The efficacy and behavioral effects of the administration of high-dose theophylline (T) and ketotifen (K) in various combinations were evaluated prospectively in a double-blind, placebo controlled study in 55 children with moderately severe perennial asthma. During a baseline period of 2 weeks, theophylline (serum level of 10-20 micrograms/ml) was administered to all the children. After this period the patients were randomly allocated into four comparable groups. The children were treated during a 12-week period with: T+K-Placebo (T group); T+K (T+K group); half-dose T+K (T/2 + K group); or placebo of both T and K (P group). During the 12-week treatment period, as compared to the baseline period, only the three groups of children who received active therapy (T+P, T+K, T/2 + K) showed a similar reduction in the number of days with asthmatic symptomatology, improvement of the total asthmatic symptoms score, and increased PEFR. The behavioral activity of the children (assessed by the Conner's rating scale) improved significantly only in the groups receiving placebo or T/2 + K. The results of this study suggest that a combination therapy of half the recommended therapeutic dose of theophylline with ketotifen can be clinically as effective as therapy with a full dose of theophylline, but with significantly less adverse behavioral effects.

Growth and pituitary-adrenal function in children with severe asthma treated with inhaled budesonide

BACKGROUND

The increased use of inhaled corticosteroids in the management of asthma raises concern about the safety of these drugs in children. We sought to determine the safety of long-term administration of inhaled budesonide in young children with asthma.

METHODS

We studied 15 children 2 to 7 years old who had severe perennial asthma. They inhaled 100 micrograms of budesonide twice daily for three to five years. Efficacy was assessed by serial evaluation of respiratory symptoms and the need for other medications, and safety by serial evaluation of height, height velocity, weight, bone age, and pituitary-adrenal function.

RESULTS

The severity of asthma decreased within the first month after the initiation of therapy, as demonstrated by a 58 percent reduction in the number of days with symptoms of asthma and a 75 percent decrease in the use of bronchodilators. This improvement was maintained thereafter. The growth pattern of all patients, including their height, weight, and bone age, was normal (as compared with standard normal values) throughout the treatment period. Pituitary-adrenal function was not adversely affected by the treatment, as demonstrated by normal serum cortisol concentrations in the morning and 60 minutes after stimulation with corticotropin, normal 24-hour serum cortisol concentrations (mean [+/- SD] of samples collected at 30-minute intervals for 24 hours, 8.4 +/- 4.2 micrograms per deciliter [232 +/- 116 nmol per liter]), and normal urinary cortisol excretion (34 +/- 9 micrograms [95 +/- 25 nmol] per day).

CONCLUSIONS

Prolonged administration of 200 micrograms of inhaled budesonide daily to young children with severe asthma does not impair growth or pituitary-adrenal function.

Safety of 1 year of treatment with budesonide in young children with asthma

Inhaled budesonide has been demonstrated to be effective and safe when it is used in the prophylaxis of severe asthma in adults and school-age children but has not been studied in younger patients with asthma. Sixteen children, aged 3 1/2 to 7 years, with severe asthma, were treated with budesonide aerosol, 200 micrograms daily, via a spacer for 1 year in an open study. One month after starting budesonide therapy, a significant decrease in the number of days with asthmatic symptomatology, mean symptom scores, use of concomitant antiasthmatic medications, and increase in the peak expiratory flow rates were observed compared with the 1 month run-in period. This improvement was maintained throughout the year with budesonide therapy. During the study period, the height and weight of the children were not significantly deviated from the expected, and their bone age advanced normally. Adrenal function, as evaluated by fasting 8 AM blood cortisol levels and after adrenocorticotropic hormone stimulation, demonstrated no adverse effects with budesonide therapy. The suspectibility to severe infections was low, as evidenced by infrequent use of antibiotics. We conclude that a 12-month administration of inhaled budesonide to preschool-age children is safe and efficient and can be useful in the management of severe asthma in this young age group.

Chemical inducers of differentiation, dimethylsulfoxide, butyric acid, and dimethylthiourea, induce selective ultrastructural patterns in B16 melanoma cells

The morphology and ultrastructure of B16 melanoma cells was examined after treatment of the cells with the chemical inducers of differentiation dimethylsulfoxide (DMSO), butyric acid, and dimethylthiourea (DMTU). The treated B16 melanoma cells seemed to be enlarged and more flattened, and to possess dendrite-like structures as revealed by scanning electron microscopy. The main ultrastructural features, depicted by transmission electron microscopy in DMSO-treated B16 cells were: a marked increase in melanin granules, migration of the melanin granules to the dendrites, and appearance of melanosome aggregates. Butyric acid did not induce melanin biosynthesis; however, it stimulated rough endoplasmic reticulum (RER) formation all over the cytoplasm. The DMTU-treated cells also showed a well developed RER accompanied by early stages of melanosomes and melanin granules. The increase in the endoplasmic reticulum was also reflected by enhancement of NADPH cytochrome c reductase activity, an enzymatic marker of the endoplasmic reticulum. The mitochondria in the DMTU-treated cells were swollen with disrupted cristae. The results indicate that DMSO, butyric acid, and DMTU induce different ultrastructural patterns in B16 melanoma cells. These findings correlate with the biochemical alterations induced in melanoma cells by these agents.

Balancing the risks of planned cesarean section and trial of vaginal delivery for the mature, selected, singleton breech presentation

The experience of mature, singleton, vaginal breech delivery over the last decade in our hospital is reviewed. This constitutes the largest series of breech delivery reported for over twelve years. Unlike all but two previous reports, we analyze our results by management policy; elective cesarean section, trial of vaginal breech delivery and cesarean section as soon as the diagnosis of breech delivery was made on labor ('expedite' cesarean operations). Six intrapartum or neonatal deaths occurred among 613 patients selected for trial of vaginal delivery--a rate of one per cent. There were none following 217 elective or 69 expedite cesarean sections. A detailed review of the literature over the last decade confirms that trial of vaginal delivery is more dangerous to the fetus and results in about one perinatal death of a normally formed infant in 200 deliveries. Apgar scores were slightly lower following trial of vaginal delivery and there were more irritable or injured babies in this group. The last intrapartum or neonatal death occurred in 1981. However, the elective cesarean section rate has increased from 14 to 33 per cent over this time period. Similarly the rate of failed trial of vaginal breech delivery has increased from 15 to 31 per cent. The proportion of failed trials was highest where the fetus was large but clinicians were poor at estimating fetal weight. Decision theory is used to examine the maternal utility of trial of vaginal breech delivery versus elective cesarean section when the intrapartum cesarean rate rises to these levels. It is shown that, from the point of view of maternal mortality and morbidity in the current pregnancy, trial of vaginal delivery maybe the more dangerous maternal option. Thus a low threshold for cesarean section in labor leads to greater fetal safety at the mother's expense. It is nevertheless concluded that maternal attitude and the long-term effects of a uterine scar should be considered in the final decision.

Growth inhibition of murine melanoma by butyric acid and dimethylsulfoxide

Treatment of B16-F10 melanoma cells with dimethylsulfoxide (DMSO) or butyric acid (BA) inhibits cell growth and delays tumor appearance in syngeneic mice. Both agents induce morphological changes in these cells. Treatment of melanoma cells with DMSO results in a marked increase in tyrosinase activity and melanin content. BA, on the other hand, does not increase melanin content and decreases tyrosinase activity. The data show that there are marked differences in the effect of DMSO and BA on melanin biosynthesis, whereas both agents inhibit cell growth and cause a delay in tumor appearance. These findings indicate that decreased proliferation of melanoma cells and induction of melanin biosynthesis are not necessarily associated phenomena.

Relationship between acetylcholine content and release in the cat's cerebral cortex

Cortical acetylcholine (ACh) release and content were measured in non-anesthetized pretrigeminally sectioned or in Dial-anesthetized cats. In 28 pretrigerninally sectioned cats a very highly significant negative correlation between ACh content and output was found. In the same preparations, 15 mg/kg pentobarbital or electrolytic lesion in the rostral midbrain decreased ACh output and increased content. Atropine (1 mg/kg i.v. or 1 μg/ml topically) increased ACh output fourfold without significantly altering content. A larger dose of atropine (25 mg/kg i.v.) increased output ninefold and decreased ACh content. In Dial-anesthetized preparations, picrotoxin-induced ACh release was accompanied by a decrease in ACh content. Pretreatment with atropine in the same preparation resulted in an enhanced effect of picrotoxin on both output and content while atropine alone (1 mg/kg i.v.) raised ACh output without decreasing content. In pretrigerminally sectioned non-anesthetized preparations, hemicholinium-3 (HC-3) did not reduce ACh output significantly but reduced content. In the presence of atropine, HC-3 rapidly reduced the high output and decreased ACh content faster than without atropine. Cortical ACh content determined following cholinesterase inhibition (surplus ACh) did not follow changes in ACh output. It is concluded that cortical cholinergic nerve endings do not maintain constant ACh content at various output rates in contrast to peripheral cholinergic nerve endings. Atropine enhances ACh output probably both by increasing ACh synthesis and by blocking an inhibitory loop. The amount of ACh released per minute varies from 1/500 to 1/13 of the amount present depending on the activity of cholinergic fibers. ACh collected from the surface of the brain does not originate directly from surplus ACh.